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"A Headache in the Pelvis" is a book that advocates physical therapy and paradoxical relaxation for the treatment of chronic pelvic pain.

What is Chronic Pelvic Pain

According to the Mayo Clinic, "Chronic pelvic pain is pain in the area below your bellybutton and between your hips that lasts six months or longer."

Thus, chronic pain in the lower abdomen, genitals and/or rectum is considered as a part of chronic pelvic pain. Common conditions that can cause chronic pelvic pain in females include endometriosis, fibroids, irritable bowel syndrome, interstitial cystitis and chronic pelvic inflammatory disease. In men, conditions that can cause chronic pelvic pain include interstitial cystitis and chronic prostatitis.

And just in case, you like jargon - here are more medical terms that are associated with chronic pelvic pain - pudendal neuralgia, prostatodynia, orchilgia, vulvodynia , levator ani syndrome and Uretheral syndrome.

Treatment for Chronic Pelvic Pain

In conventional medicine, it is believed that the pain may be caused due to a problem with the pelvic organs. In many cases, antibiotics are prescribed for an extended period of time. It is also treated with antidepressants and psychotherapy assuming that it is a manifestation of psychosomatic condition.

Wise-Anderson Protocol

The authors of the book, Dr Wise and Dr Anderson, support a relatively new viewpoint of pelvic pain being caused due to the pelvic floor musculature instead of the pelvic organs. This is especially true in cases where there is no clear etiology.

Specifically, they claim that the pain is caused due to tight pelvic floor muscles. The tightness may be caused as a response to psychologically stressful situations. It can also be caused due to physical trauma to the structures in the pelvis like an injury. In fact, in many patient cases that I have come across on online forums, people report that the pain started after an episode of anal fissure or a hysterectomy. The authors suggest that such patients usually are already predisposed to pelvic floor dysfunction because of their personality traits and the way they internalise the day to day stress. An example of such a group of people is those with type A personalities.

The book starts with a description of the various conditions that are believed to be associated with pelvic floor dysfunction. The conventional medical treatments for these conditions are included in the description. Next, the authors discuss their beliefs about what causes chronic pelvic pain. In their words, "Our viewpoint, very simply, is that pelvic pain is the result of a chronic hypertonicity in the pelvic floor, fed by protective guarding, anxiety and tension" .

They then describe their protocol which consist of chiefly two parts. The first is physical therapy to reduce the trigger points in the pelvic floor. The second is learning to relax your body especially your muscles. This relaxation technique is called as paradoxical relaxation. It is called so because according to the authors, relaxation seems to happen best when the patient becomes conscious of and accepts the tension/tightness in the pelvic floor rather than actively focusing on releasing the tension.

Each of the aforementioned modalities as discussed in details in a separate chapter of its own. In the physical therapy chapter, the authors include detailed diagrams of both the male and female pelvic anatomy. They describe various stretches for the muscles in the pelvic floor adjacent areas. They also talk about techniques such as skin rolling to loosen the fascia. In the paradoxical relaxation chapter, the authors explain how a patient can reduce her pain by learning to relax her body throughout the day. This is called as moment to moment relaxation. The patient is taught to check with herself throughout the day to see if she is holding tension in the pelvic floor and then remind herself to let go of the tension. The authors also ask patients to not 'catostrophize' the illness in periods of heightened pain.

For me, the description of paradoxical relaxation was perhaps the most useful takeaway from the book. I read that multiple times. Every time I would go back to it, I would gain a new insight. The psychotherapy techniques discussed in the section can be applied to other forms of chronic pain also.Or for that matter, any other chronic illness as well. I had come across other books with similar content earlier but it is only after reading A Headache in the Pelvis that I was able to properly comprehend the subject and be in a position to practice it. It is for this reason alone that I recommend buying the book.

The book also has an interesting reference to the more common ailments of chronic constipation, anal fissure and hemorrhoids. According to the book, even though the conventional treatments include surgery, it does not attempt to address the root cause which may be stress induced muscular spasm in the pelvic floor.

At this stage, I must emphasise that I have not been able to recover with the recommended physical therapy and paradoxical relaxation technique. However, there are success stories of a number of patients on online forums such as Chronic Prostatitis and IC Network. Many have been able to recover on their own after reading the book and doing physical therapy on themselves. I not only had a professional physical therapist but also eventually went and attended the authors six day course in California. It was an expensive proposition but I was desperate. I don't recommend people going to the course until and unless they read through the book and find at least some of the techniques described in it useful in managing their pain.

There have been some negative reviews on the book also. One of them is listed here (CAUTION - please exercise discretion reviewing this link as the website discusses adult content).

My response to unfavorable comments is that as a patient suffering with an intractable illness, one has to try out different options with full sincerity and then pick and choose the one which is most beneficial. Even the most vocal critics of the book will agree that more relaxation and less anxiety will always be helpful in managing chronic pain. And even if the pelvic pain is because of a pelvic organ dysfunction, there is a high probability that the muscles will get into spasm because of the pain. So any treatment will have to include the elimination of trigger points and muscle relaxation.

Finally, in the absence of any other alternative, physical therapy and paradoxical relaxation continue to be the only credible conservative treatment protocol. I recommend this book to anyone who suffers from chronic pelvic pain and is searching for answers to manage it.

Comparison with Other Books

Here is a brief comparison between other books on the same topic and "A Headache in the Pelvis". Just to be clear, I don't imply that the other books are not worth reading. Rather, I would say that "A Headache in the Pelvis" should be read first. Then, if you have enough time and energy, you can read the rest of the books.

Healing Back Pain has been an Amazon bestseller and is a recommended read for a variety of chronic situations. However, the book actively discourages any form of physical therapy. The reason is because the books hypothesis is that the pain is actually being cast by the subconscious which is creating pain in order to distract you from confronting and resolving the difficult emotions that are embedded within your subconscious. Thus, continuing with physical therapy is actually continuing with the distraction that the subconscious wants you to do. Instead, the book advocates journalling and psychotherapy counselling in order to understand your emotions at a deeper level. Despite the somewhat unconventional purposes, there are lots of success stories some of which can be read at a very active support forum at tmswiki.org. However, even in 2017, there is still no concrete process of being able to confronting your emotions and be able to resolve them. Some people claim that there pain disappeared while they were reading the book while others like me, have spent years trying to work on themselves without much success. I, therefore, suggest following a much more concrete approach outlined in the "A Headache in the Pelvis" at first. If you do not make any headway then you can 'Healing Back Pain"

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It's a shame that there always have to be some theorists writing books that make something psychological out of a medical condition. While I can see how stress might make any tense muscles tense further, attributing the condition itself to stress seems devaluing of the patients who suffer these often long-term conditions and is rather unscientific and unquantifiable. As in so many other conditions this can stymie and delay important medical discoveries because nobody's looking at other possible causes all that hard.

If it were that simple and the cause had been found then it would be something a few sessions of psychotherapy and stress relief techniques would fix and the patient would then be on their merry way, not suffer for many more years.

I hope not too many patients buy into that theory, as it might make them stop persuing real answers. I find that this seems to be the go-to whenever doctors are stumped and can't figure out the cause of something, really kind of a cop-out and it doesn't do the patient justice.

Physical therapy might help something like this to some degree, as it strengthens and develops muscle control, (as any exercise generally does), but probably isn't the full answer either.

Now I think the theory of physical trauma to the area makes much more plausible sense. Perhaps injury affects the nerves in that area in some way or the muscles are forced to adapt in awkward ways after an injury whether from an accident, infection, or other.

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